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HomeMy WebLinkAbout0035 LINDEN AVENUE - Health 35 Linden Ave Centerville A= 208-133 T I r fHealth Department Drop-Off Hours: 8:00 AM - 4:30 P.M Town of Barnstable Received by Health n-I FT"E�ati Regulatory Services Department on Richard V.Scali,Director :. , L �0r Public Health Division , RFD MPS A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE Property Address: 136 LwJ eo � � o l Assessor's Map/Parcel Number: 310 — IhA Applicant(s) Name: L v=1 S &,J E vc- C u-'I�c. Phone: I E-Mail: 9_y6—C6-- ►"q 621 Lo�"� 0 - 8 i 6- Size of Lot: 2a. How many bedrooms exist at your property now? 2b. How many bedroom are you planning to add as part of the Accessory Affordable Apartment Program application? 2c. How many bedrooms total are proposed at this property(including the Accessory unit)? a 2e. Is the proposed Accessory Apartment contained within:. the main house; OR a detached structure 2f. Submit floor plans for all buildings on the entire property. Show all existing rooms in the dwelling and the proposed accessory apartment. Label each room clearly. Label measured width of all open doorways. Use straight edge for hand drawn plans and be sure all labeling is legible. Signed: L. �`"----- Date: 1 ) s 1 , I 1 T ' ` i � o'er �o �'.. G— l c _ GfG'I\ivl it ir� ". n i^el�► - � v ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE FOR STAFF USE ONLY 1. Is the dwelling connected to Town sew r? Ye ❑ No 2. Dwelling located ❑ INSIDE ❑ OUTSIDE the Saltwater Estuary Protection Zonh/,4 3. Dwelling located ❑ INSIDE ❑ OUTSIDE public supply well Zone of Contribution I 4. Dwelling is connected to ❑ ON-SITE WELL 0-P'[1BLIC WATER 5. Disposal works construction permit on file? ❑ Yes ❑ No 6. If yes, how many bedrooms were allowed by this permit: bedrooms } 7. Were building permits obtained for additional bedrooms? ❑ Yes ❑ No 8. Engineered septic system plan: a. On file at the Health Division? ❑ Yes ❑ No / b. If proposed accessory unit is detached from principal dwelling, is that plan on file? ❑ Yes ❑ No 9. Existing septic system capacity is bedrooms - ;t For the accessory unit to receive approval from the Health Department the following action must occur: ❑ Existing system accommodates proposed additional bedroom(s) ❑ Upgrade to accommodate additional bedroom s p9 existing system stem Y ( ) ❑ Must remove a bedroom from the main house ❑ Must connect detached structure to the existing septic system .h ❑ Must install septic system for the detached structure ❑ Other e igne - Date-2/`S e ¢ ;lab C_ t _ 2 z �� men �� S � Co��l�Co Peet-&r C '' , ce_iles / e rp_q_p_ e5 S, fpal s> iOfo � 1 � i -- u f IJ- 7 l � 4 t v, i 1 LJW'1A, �t)wiV No. / 3 ?1 t r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Mioposal *pstrm Conetruttion Permit Application for a Permit to Construct( ) Repair( 4pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.'a � Owner's Name,Address,and Tel.No. Assessor's Map/Parcel -e ;2-0 — p Installer's Name, �ddrep,and T!1.No. Desi er's Name,Add ess and Tel.No. f—F to eY C©rJS� �0L3 QS_A Type of Building: Dwelling No.of Bedrooms Lot Size 33 sq.ft. Garbage Grinder( A),10 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) LA 40 gpd Design flow provided �J �� gpd Plan Date N6 V 74 Number of sheets / Revision Date A-I1t Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date Application Approved b Date Application Disapproved by Date for the following reasons Permit No. QQ i, 3 7�� Date Issued 'a No. 3 ?1 Fee /00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: u PUBLIC HEALTH DIVISIONt TOWN OF BARNSTABLE, MASSACHUSETTS Yes - 2ppYiration for -M opomak �&pstem Construction Vermit Application for a Permit to Construct( ) Repair( Kpgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.'% Owner's Name,Address,and Tel.No. Ce—A Assessor's Map/Parcel YVA Installer's Name A ddre$s,and Tel.No. Desig er's Name Ad ess,and Tel.No. K-< /-f to yy CovJ<< 0Lt0 o V Type of Building: Dwelling No.of Bedrooms Lot Size 5'(� sq.8. Garbage Grinder( A�10 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) L4 y gpd Design flow provided �J S� gpd Plan Date IJ6V �, ol-012 Number of sheets / Revision Date Title Size of Septic Tank Typuf-S."A S Description of Soil i Nature of Repairs or Alterations(Answer when applicabl`e X i t, 1 Date last inspected: ------- Agreement: The undersigned agrees to ensure the construction and maintenance:of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envirbnmental Code and not1to place the system in operation until a Certificate of P , Compliance has been issued by this Board of Health. Signe _ r,.i. t Date Z Application Approved b Date 7��07 : Application Disapproved by Date for the following reasons j Permit No. _:)O ) c; 7 Q Date Issued 'a I --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of tom--pliattre THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by C \L0 1y/ at 3 L��.�ch PtV e- (2ew1 ey v. UZ_►-has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No.D-L/D 3? dated G Installer C t"Y_ &AJ-S'Z " Designer l�c�ta►. dc,,124 _ #bedrooms Approved design flow y S gpd The issuance of this permit shall not t be cynstrued as a guarantee that the system wil n ti signed. Date /�/3 a// 2f` Inspector -------------------------------------------------------------- 1------------------ ---------------- = ----------------------------------- No. Q l d� �J / Fee �a THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *psttr Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade -( ) Abandon( ) System located at 3th Au r evert e r"V i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction m st be leted within three years of the date of t s permit. �I Date I ` Approved FROM :down cape engineering inc FAX NO. :15083629ee0 Jan. 16 2013 09:36AM P1 t�N n '11.1mllum TP. 4'161ef, Dfirccuio)c T Ubli llflahka 500�-962-4641 Fax: m age ycrmitg OW A Address; Pot MA -14X-Iinr�;ef On. wss a pez=df to in-min Li al bitsc:d-on a di.sipi drawa'ny ('Iddruss) it ne-P-Liu, systp.1-1 3,hrve was ij-,stalkd 9111,1Fta-LbEdly' 2.CCC1Tdim[,r fn the d.nsi.pu Nliich may mfJ-ilde miner itpproved chang:--,s mach aS 1-itCYRI RdOOPtiOn.Offhe cjj.,,'LTib-cjt.jo,n box and/or zxp Iir-,I-811k. I certify that th(': 92.PtiC, cefermew.1 itbove was installed wiLh major cl-iangk* {i.e. gTeaLe's t.b."In I W latpu�d r(docat"oll of i1jr, SAS orally V(-.',rt1Ci3-1.mluco 40:11 Of',ITIY of the su.-Ptir- Wid-i stm - T,ma1.Re,17jjLjt'0LLS. I 111-m roviglan or us-I'Alitt by to llollu-w- tkOFM I)AW1 EL A OJALA CNIL NO,46502 NAL Oe"n.griel!"3 ,tarlp 1,10 ITY..A. J. f T4),SZEJT U1` k'l.I. Bllonj :vFTS FQ,R.N( AN,D A8--.'8TJ1LT L,EITIV JU_t!y Tj-t�,�,H A TT.11 DfVfS7D 1!P.T1iF1f:;'1TirM hfirm 3-26 U4,dot-, Town of Balrnsiable P� � 72? oar , Departi rent of Regulatory Services ]Public Health Division DateMAM 200 •rFU�1Kt�, lupin Street,Hyannis MA 02601 Date Scheduled l / Time Fee Pd. 0. Soil SuitabiliO .Assessment for Se .disposal Performed By: Witnessed By: Location Address LOCATION& GENERAL INFORMATION 3 5- �J nn �p1 V���,QMq �/�. Owner's Name W�l/`'� Address Assessor's Map/Parcel: a0�//3� Engineer's Name �0 �e' NEW CONSTR 6d UCTION /// REPAIR Telephone# / Tel U� Land Use: 1 lz— es 96�t _ 5Jo CJ P ( ) Surface Stones AIC"e- Distances from: Open Water Body. ft possible Wet Area ft Drinking Water Well � � ft Drainage Way ft Property Line —__ft Other ft SI�TCII:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands•fn proximity to holes) u� AC s = 0 Al zzo A 1 0 cn • N X-1 r fit (�1 .V r"n Parent material(geologic) 616i""C4 1 T�! Depth to 13adrock wV Depth to Groundwater- Standing Water in Hole: IV1A Weeping from Pit Face Estimated Seasonal High Groundwater " DETERMINATION FOR SEASONAL 111 ' WATER TABLE Method Used: GH Depth Observed standing in obs.hole: In. Depth to soil mottles: lit, Dcpt6 to wcepIng from side of obs.hole: In, Groundwater Adjustment f[. Index Well# Reading Date: index Well]eYol. _ Adj.factor- Adi,Groundwater Leval ]PERCOLATION• TEST bate i0-3/-)Z-Thne )0'30 Observation � Hole# Tlme at 9" 1 1,GU Depth of Pero 4 d Time at G° 11.1 12,0. Start Pre-soak Time @ Time(9"-G") i 2,3o - End Presoak • / RateMln./iach LS/ t,.7 - Sitc Suitability Assessment. Site passed /\ Sitq Failed: Additional Tcsting Needcd(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***I£percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q.,\S EPTIC\PERCFORM.DO C DEEP—OBSERVATION HOLE LOG Hole# I Depth from Soil Horizon Soil Texture .Still Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure, Stones,Boulders. o i ten;y,%•Gravel) G- iy A S 1oyA'q/3 14 - 3� DEEP 013SE+RVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (structure,Stones,Boulders. - G � � � onsis en, %Gravel) 10 YR /j, ly- 3� B L S 10yR /g DEEP OBSERVATION HOLE LOG Hole#. Depth from Soil Horizon Soil Texture Soil Color Soil Other. Surface(in.) (USDA) (Munsell) Mottling (Structure,Stories,Boulders. Co i toncy, G e we i DEEP OBSERVATION HOLE LOG Hole# r' Depth from Soil Horizon Soil Texture Soil Color Sall Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones'.Boulders. • �- Co si ton ' r • Flood Insurance Rate Map, Above 500 year flood boundary No_ Yes "Within 500 year boundary No X Yes ' Within 100 year flood boundary No. & Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? -�e S If not,what is the depth of naturally occurring pervious materiall Certification I certify that on 1 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me,consistent with the required training,expertise and experience described in 110 CUR 15.017. Signature ��—®�"`"�L Datb Q:15.EPT1aPERCP0RM.D0C I r Commonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information I ` on the computer, use only the tab 1. Inspector: J key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones TitleV Septic Inspection Company,Name 74 Beldan Ln. Company Address too Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maipt nance of:,pn sites sewage disposal systems. I am a DEP approved system inspector pursuant to,;! ion 15 340 0 Title 5(310 CMR 15.000).The system: �r ® Passes ❑ Conditionally Passes ❑ Fails.," I, ❑ Needs Further Evaluation by the Local Approving Authority _ e 5/29/2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurta a Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 35 Linden Ave Centerville is served by a Title V septic system consisting of a block cesspool with a 1000 gallon pre-cast leach pit overflow. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No" ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments e 35 Linden Ave Property Address Henderson Owner Owner's Name information is Centerville Ma 02632 5/29/2012 required for every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A)' 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on"the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts yjTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts U�t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool I ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ® cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •'� 35 Linden Ave Property Address Henderson Owner Owners Name information is required for every Centerville Ma 02632 5/29/2012 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °f 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 x 1000 gallons ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was video inspected and found to be dry with no visible sign of past hydraulic overloading. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert — Depth of solids layer Depth of scum layer Dimensions of cesspool 6x6 Materials of construction concrete block Indication of groundwater inflow ❑ Yes ® No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool was dy at time of inspection. Cesspool was structurally sound, no loose block. Outlet pipe has pvc tee. Cover is 1 B" below grade. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately e' r P P w /'/'� f P I -1 Z 4r 1 'M1 01 /3-r Z .55'�� C- C-Z L2' t5ins-11 M O Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour maps. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official inspection Forth:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 35 Linden Ave Property Address Henderson Owner Owner's Name information is required for every Centerville Ma 02632 5/29/2012 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE I LOCATION 3,5 SEWAGE# 90I Z — 3 9 9 VILLAGE C e�re wy,& ASSESSOR'S MAP&PARCEL o'W Cq 1 33 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 105D 1 k�_ `Tvr- (size) I 1 rX 'Y Z NO.OF BEDROOMS OWNER PERMIT DATE: 7-1 1 Z— COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Fac' fy Feet Private Water Supply Well and Leaching Facility(If any wells exist o site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facilit Feet FURNISHED BY - �� rrl v 0 ® e�. F—)VI T 76- fAk t. E ssoec r. �P G eac�l p/T CeWTe� 4//&( S- SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES MARKED WITH MAGNETIC TAPE OR d R ' PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS APPROX. NGVD Route 28 016 P05 ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2" PEASTONE OR GEOTEXTILE PROVIDE It SPECTION PORT TO WITHIN 3" OF FINAL GRADE 0� MAIN DWELLING 2. MUNICIPAL WATER IS EXISTING TOP FOUND. EL. 50.1' FILTER FABRIC OVER STONE 49 9 MINIMUM .75' OF COVER OVER PRECAST 2q SLOPEE EQUIRED OVER SYSTEM EEO3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. PRECAST H-10 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS TO BE AASHO H-10 RISERS (TYP.) a•.. 2'0 4"OSCH40 PVC 2" DOUB[F WASHED PEASTONE PIPES LEVEL 1ST 2' S. PIPE JOINTS TO BE MADE WATERTIGHT. r OR GEOT ILE FABRIC 45.8' 4 *47.38 10�� 1500 GAL H-10 14" 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE 4j g' TEE SEPTIC TANK TEE ; WITH 310 CMR 15.000 (TITLE 5.) 45.65 0 0 0 0 0 0 0 45.29' 0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND o Locus o� GAS BAFFLE; °o°o°o°o°o° NOT TO BE USED FOR LOT LINE STAKING OR ANY 80 2' OTHER PURPOSE. 4' LIQ. LEVEL (ACME OR EQUAL) 45.47' 45.30' o od 43.29' G •tia�' M1 ' •' H-20 3050 INFILTRATORS 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. m 00000000000000000000o0o0o0o0o0o0o0o0o0o0o0o0� " orseshoe Ln 00000000000000000000000 6 MIN. SUMP �o '0000000�0�0�0�01 0000000000�0�0�0„0„0000000. 12" MIN. INT. DIM. 9. COMPONENTS NOT TO BE BACKFILLED ORV-, . 3/4" TO 1 1/2" DOUBLE WASHED STONE a CONCEALED WITHOUT INSPECTION BY BOARD OF 6" CRUSHED STONE OR MECHANICAL HEALTH AND PERMISSION OBTAINED FROM BOARD /odd ocus BARN INVERT = EL. 47.5'* (MIN% SLOPE) COMPACTION. (15.221 [2)) OVERALL DIMENSIONS TO OU'i'SIDE OF STONE: 41.5' X 10.25' OF HEALTH. 1 5.79' ( % SLOPE) ( 1 % SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND �On��+ MAP MAIN DWELL. 73' VERIFYING THE 18' , LEACHING OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OTION OF ALL UNDERGROUND F LOCUS /`1f SEPTIC TANK D BOX 3 BARN FNDN.- 15' FACILITY WORK. NOT TO SCALE BOTTOM TH-1 & TH-2 37.5' NO GROUNDWATER FOUND 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 208 PARCEL 33 *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL -\ SHALL BE REMOVED 5 BENEATH AND AROUND THE UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS \ DIRT\ PROPOSED LEACHING FACILITY. PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM / \ VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE \DRIVE \ 12. EXISTING LEACHING FACILITY SHALL BE PUMPED IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT O TEST HOLE LOGS // �� \ +48.\3 AND REMOVED OR PUMPED AND FILLED WITH CLEAN BY HEALTH INSPECTOR K47.83 �' \ SAND. D. GONSALVES, SE \ \ PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVE ENGINEER: \ BY THE BOARD OF HEALTH REVISED DURING A PUBLIC WITNESS: D. DESMARAIS, RS �/ �� \\ \ HEARING HELD ON AUG. 4, 2009 R DATE: 10/31/12 // \ \ \ 3) FAILED SYSTEMS ONLY: SOIL ABSORPTION SYSTEM 41 \ \ INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW PERC. RATE _ < 5 MIN/INCH \ \ GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) \ AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS CLASS I SOILS P 13777 4- \ BE LOCATED MORE THAN SIX FEET BELOW GRADE. \ \\ 0 \ �+ n ELEV. ,L--2 J� / , , � 49.349 O's V 49.5 0 v 49.5' Jam/ � 49 SYSTEM DESIGN: A A > 47.89 49.64 \ SL SL �\ I 1 BENCHMARK GARBAGE DISPOSER IS NOT ALLOWED 3 10YR 4 3 I EXISTING COR CONC. BLKHD 10YR 4 / / ° DWELLING ° \ EL. = 50.3' 14 14 �- z I TOP FNON. ELEc // \ DESIGN FLOW: 4 BEDROOMS @ 110 GPD = 440 GPD B B f 49.f63 EL. = 50.08' METER g. _ _ / , USE A 440 GPD DESIGN FLOW -- LS LS z -- / i / SLEEVE SEWER LINE WHERE WITHIN 36" 1 OYR 5/8 46.5' 36" 1 OYR 5/8 46.5' o I W4 23 10' OF WATERLINE USE TANK: 440 GPD (2) = 880 I USE (1) H-10 1500 GAL. SEPTIC TANK C 1 C 1 W I 10 Z�•Jc9AQ9 PERC FS FS �/ Iy f LEACHING: I 9.8 `� SIDES: 2 (41.5 + 10.25) 1.85 (.74) = 141 GPD 720* 2.5Y 6/4 43.5' 72" 2.5Y 6/4 43.5' I I �$cov. 02 EXIST. BOTTOM 41.5 x 10.25(.74) = 314 GPD BARN #49.6 C2 C2 I ATIO 49.9° FFLOOR 49.81 EL.=50.4' \\ TOTAL: 615 S.F. 455 GPD / }49.54 POSS. CP 5 8 49. USE (5) INFILTRATOR 3050'S WITH 3' STONE I / �'Fs 1 M/C$ M/CS / I +50.54 (SEE NOTE j 5 1 4 6 ��. ALL AROUND 47.31 I 32" TREE 12) +� \.92 ?i�• �{49.8 .7n 1OYR 6/6 1OYR 6/6 0 o .49 144" 37.5' 144" 37.5' � I + 8 NO GROUNDWATER ENCOUNTERED / + 01 +5 .06 �0 -�� 2 1 MA � +49 �sEEENo ooi 9 93 }49.9 2 TM 1 . APPROVED DATE BOARD OF HEALTH I \49.36 �.� +,0.66 5 36" TR E ��y � TITLE 5 SITE PLAN ��9.81 ���✓ oS /y \ OF +43.86 .71 N, + 8 A� J 49.61 35 LINDEN AVENUE CENTERVILLE LOTS 5&6 \ 149.77 *49.80 PREPARED FOR 35,961 SFt � \ \ UPOLE THE HOUSE CO. APPROX. \ PROP. VENT WITH CHARCOAL FILTER �+49.83 \+49.76 AND BUGSCREEN (FINAL PLACEMENT BY NOVEMBER 7, 2012 BENCHMARK: CORNER OF \ / CONTRACTOR WITH HOMEOWNER CONSULTATION) off 508-362-4541 CONC. SLAB AT EL. 50.2' \ �a `�' OF �H uF r� .�.�,a s.� ,�,, 0.� pis 1, fax 508-362,-9880 DAN!EL--A. cs'%��DAME` �Xli rn downcape.com \/ OjA!A A. �I' • • • 'K 49.81 j o - � - Pi . l.' down cape engIneel 76VI 117 • C14 el s, O,�ALA Scale: 1"= 20' cv �ti ur,Oz o �. `��� civil engineers sTF r \�q e s� land surveyors 0 10 20 30 40 50 FEET 18 L 939 Main Street ( Rte 6A) 2-2 7 , DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675